Curbside Consultation of the Liver: 49 Clinical Questions

Mitchell L. Shiffman, MD

Question 46: My Patient With Hepatic Encephalopathy Continues To Be Mildly Confused Despite Taking Lactulose Twice Daily And Having Multiple Episodes Of Diarrhea Daily. Should I Increase The Dose Further? (continued)

Douglas M. Heuman, MD; Adil Habib, MD

Generally, the answer to this question is “No.” Lactulose is an effective treatment for hepatic encephalopathy, but it is not innocuous and should not be used promiscuously. Lactulose dosage should be titrated to produce 2 to 4 loose stools per day. Increasing lactulose beyond this point does little to improve encephalopathy while greatly increasing adverse effects such as dehydration, electrolyte derangements, incontinence, perianal irritation, and skin breakdown. Indeed, the metabolic derangements caused by excessive diarrhea (hypernatremia or hyponatremia, hypokalemia…